Global, regional, and national burden of migraine in 204 countries and territories, 1990 to 2019

Evidence supporting the role of hypertension in the onset of migraine

BACKGROUND

The association between hypertension and migraine remains unclear.

OBJECTIVE

The aim of this study employ multi-layered evidence chain that revealed the association between hypertension and migraine.

METHODS

We first strictly included data from the NHANES 1999-2004 population and applied logistic regression, subgroup analysis and RCS to assess the correlation between hypertension, SBP, DBP and migraine. Meanwhile, LDSC and Mendelian randomization were conducted based on the GWAS to determine the causal relationship between hypertension and migraine. Inverse-variance weighted (IVW) was used as the primary method. Sensitivity analysis and Colocalization analysis were performed to confirm the robustness of the results. LDSC validated the genetic correlation between traits. Enrichment analysis revealed their underlying biological mechanisms.

RESULTS

After strict inclusion in NHANES, 10,743 participants were included. The logistic regression showed a significant correlation between hypertension (OR = 1.21 [95% CI, 1.08-1.36], FDR < 0.001)、DBP (OR = 1.01 [95% CI, 1.01-1.02], FDR < 0.001) and migraine. This association did not show significant group differences in subgroup. The MR results further supported the existence of a significant causal relationship between hypertension (OR = 1.77 [95% CI, 1.43-2.30], FDR < 0.001)、DBP (OR = 1.02 [95% CI, 1.01-1.03], FDR < 0.001) and migraine onset. Additionally, the RCS analysis showed a linear relationship (P non-linear = 0.897) between the two. The LDSC result showed a significant genetic correlation between the two (Rg = 0.1092, SE = 0.028, P < 0.001).

CONCLUSION

The development of migraine caused by hypertension is mainly realized through high DBP.

Migraine treatment with CGRP monoclonal antibodies: patient evaluation of a mandatory treatment holiday in Belgium

BACKGROUND

Monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway have emerged as a promising preventive treatment for migraine. In Belgium, patients receiving these antibodies must adhere to a mandatory treatment holiday of three months. This study investigated the patients' experiences during this treatment holiday.

METHODS

A prospective study was conducted among 243 patients from nine headache clinics in Belgium receiving treatment with erenumab, fremanezumab or galcanezumab. Participants completed a structured questionnaire during their yearly follow-up visit after the treatment holiday. The questionnaire assessed the subjective migraine evolution and anxiety levels, and perceived usefulness of the treatment holiday.

RESULTS

The majority of patients (86.0%) reported worsening of migraine symptoms during the treatment holiday, 59.4% of them experiencing deterioration already within the first month. For 5.9% of patients, this occurred beyond the 3-month mandatory holiday period, delaying treatment resumption. Improvement was reported by 3.0% of patients, while 11.0% experienced no change. Anxiety surrounding the treatment holiday was reported by 45.0% of participants, with 18.6% experiencing very high levels of anxiety. A significant association was found between anxiety and subjective migraine deterioration (p = 0.012). Nearly half (49.1%) of the respondents found the drug holiday overall useful in gaining insight into the need for continued treatment, 22.6% considered it even very useful.

CONCLUSION

A rigid, mandatory treatment holiday of two to three months poses significant challenges for a substantial subset of patients, leading to rapid migraine deterioration and increased anxiety. The observed association between migraine deterioration and anxiety highlights the need for patient education strategies. Policy makers should consider these findings to develop more flexible, patient-centered treatment approaches that optimize outcomes.

Association between milk consumption and migraines among American adults: national health and nutrition examination survey

BACKGROUND

Migraines have been associated with nutritional imbalances within the brain, sparking ongoing interest in the possible association between dietary elements, including milk intake, and the occurrence of migraines. Nevertheless, the exact nature of the connection between milk consumption and migraines remains unclear.

METHODS

This cross-sectional analysis sought to explore the association between milk intake and the prevalence of migraines. The study utilized data from individuals aged 20 and above who participated in the National Health and Nutrition Examination Survey from 1999 to 2004. In our study, we meticulously gathered comprehensive data on severe headaches or migraines, milk consumption, along with critical variables such as age, sex, marital status, and body mass index, among others. Milk consumption among participants was ascertained through a questionnaire. Logistic regression modeling and subgroup analyses were employed to evaluate the association between milk consumption and the incidence of severe headaches or migraines.

RESULTS

Among the 8850 participants, 19.98% (1768/8850) were identified as having migraines. Compared to individuals with only regular/whole milk consumption in the past 30 days, the adjusted OR values for only skim milk consumption in the past 30 days were 0.73 (95%CI: 0.60-0.89, p = 0.001), 0.78 (95%CI: 0.64-0.95, p = 0.014), and 0.77 (95%CI: 0.63-0.93, p = 0.009), respectively.

CONCLUSION

A notable association was detected between the type of milk intake and the occurrence of migraines. These results lay the groundwork for future investigations into the role of milk consumption in migraine management, potentially informing strategies for alleviating migraine symptoms.

Activation of δ-opioid receptors blocks allodynia in a model of headache induced by PACAP

BACKGROUND AND PURPOSE

Pituitary adenylate cyclase activating polypeptide (PACAP) is a human migraine trigger that is being targeted for migraine. The δ-opioid receptor (δ-receptor) is a novel target for the treatment of migraine, but its mechanism remains unclear. The goals of this study were to develop a mouse PACAP-headache model using clinically significant doses of PACAP; determine the effects of δ-receptor activation in this model; and investigate the co-expression of δ-receptors, PACAP and PACAP-PAC1 receptor.

EXPERIMENTAL APPROACH

Cephalic allodynia to low doses of acute and chronic PACAP were tested. A triptan (sumatriptan) and a CGRP receptor antagonist (olcegepant) were tested in this model. The δ-receptor agonist SNC80 was tested in PACAP and CGRP-induced headache models. Expression of PACAP, PAC1, CRLR and δ-receptors was determined using in situ hybridisation.

KEY RESULTS

Low doses of PACAP produced dose-dependent acute and chronic cephalic allodynia, blocked by sumatriptan but not by olcegepant. The PAC1 antagonist (M65) did not inhibit CGRP-induced allodynia. There was moderate co-expression of PAC1 and CRLR transcripts in migraine-related regions. SNC80 blocked PACAP- and CGRP-induced allodynia. There was low co-expression of PACAP and δ-receptors in brain regions measured. However, there was high co-expression of PAC1 and δ-receptors in somatosensory cortex, hippocampus and trigeminal nucleus caudalis.

CONCLUSION AND IMPLICATIONS

We developed a translationally significant model of PACAP-induced headache, which was mechanistically distinct from CGRP. Activation of δ-receptors blocked PACAP- and CGRP-induced allodynia, and δ-receptors were highly co-expressed with the PACAP-ergic system. Future studies will examine the functional relationship between δ-receptors and PAC1.

Forecasting migraine attacks by managing daily lifestyle: a systematic review as a basis to develop predictive algorithms

Recent studies attempting to develop forecasting models for new migraine attack onsets, overviewing triggers and protectors, are encouraging but necessitate further improvements to produce forecasting models with high predictive accuracy. This updated review of available data holds the potential to enhance the precision of predicting a migraine attack. This study aims to evaluate how lifestyle factors affect migraine frequency in adults with episodic migraine, to contribute to the development of an effective migraine forecasting model. A comprehensive search of databases, including PubMed, ScienceDirect, Google Scholar, and Scopus, was conducted considering studies published from 2018 to December 2023, following the PRISMA guidelines. Critical evaluation was conducted using the Joanna Briggs Institute's appraisal tools. The lifestyle modifications examined in this review included dietary habits, physical activity, sleep, and stress management. Of the 36 studies analysed, which predominantly exhibited low to moderate bias, 18 investigated dietary habits, 7 explored physical activity, 11 assessed stress management, and 5 investigated sleep patterns. The evidence from these 36 studies advocates for the implementation of lifestyle modifications in migraine management. Furthermore, these outcomes carry valuable implications from the standpoint of migraine forecasting models. The most consistent results were observed in relation to specific diets, dietary supplements, and physical activity. Although trends were noted in stress management and sleep, further research is required to elucidate their influence on migraine frequency and their integration into a migraine forecasting model. This study is registered on PROSPERO (ID CRD42024511300).

The burden of migraine in Mexico: a database analysis of migraine-related visits to emergency departments in Mexico's Ministry of Health (MMoH) hospitals

BACKGROUND

The burden of migraine in Mexican Emergency Department (ED) settings remains understudied. This study aimed to determine the frequency of migraine-related ED visits within the ED Mexican Ministry of Health's (MMoH) database and analyze their demographics and treatment patterns.

RESEARCH DESIGN AND METHODS

This retrospective study analyzed MMoH database of ED visits between 2013 and 2022. Visits with migraine diagnosis were selected using ICD-10 codes. Demographic characteristics, geographical location, and time of consultation were described, medication use patterns were analyzed.

RESULTS

Between 2013 and 2022, there were 1,022,450 reported ED visits related to primary headache (0.6% of all ED visits), there were 179,618 migraine-related ED visits (19% of all headache visits). Females represented 78% of visits. Visits peaked in 2014 (20,066) and were the lowest in 2019 (8,273). Medication was used in 21% of visits, NSAIDs being the most frequent (15%). Triptan use was low (0.04% of all migraine visits).

CONCLUSION

Our results highlight the significant burden of migraines on Mexico's healthcare system and the importance of considering age and sex in the approach to migraine ED visits. An update in therapeutic strategies for migraine in Mexico is needed to improve patient outcomes.

Trends in migraine and tension-type headaches in South Asia: findings from the Global Burden of Disease Study 2021 (1990-2021)

Background

Headache disorders, including migraines and tension-type headaches (TTH), are major contributors to global disability. In South Asia, where these conditions are often underdiagnosed, their burden has grown substantially. This study evaluates trends in headache disorders across eight South Asian countries from 1990 to 2021, using data from the Global Burden of Disease (GBD) Study 2021.

Methods

Data from the GBD study were analysed to evaluate incidence, prevalence, and years lived with disability (YLDs) for headache disorders and their subtypes. Trends were assessed using absolute numbers and age-standardized rates, with demographic patterns by age and gender examined to identify vulnerable populations. Joinpoint regression analysis was employed to detect significant temporal shifts.

Results

From 1990 to 2021, headache disorders in South Asia rose from 114.2 million to 206.8 million in incidence, and from 367.4 million to 698.5 million in prevalence, with YLDs nearly doubling from 6.0 million to 11.6 million. Migraines accounted for 294.4 million cases, while TTH contributed 495.4 million cases, with YLDs increasing by 92.88 and 99.35%, respectively. Afghanistan saw the highest relative growth, while India contributed the largest absolute burden. Women and middle-aged adults were disproportionately affected, with the highest prevalence observed in females aged 30-34 years. The Maldives showed dramatic increases in TTH-related YLDs, highlighting disparities in smaller nations.

Conclusion

The rising burden of headache disorders in South Asia highlights the need for region-specific strategies targeting high-burden subtypes, countries, and vulnerable populations to mitigate their disabling impacts.

Unmet needs in the management of migraine in Greece from the perspective of medical experts: a Delphi consensus

Introduction

Migraine is a chronic, debilitating neurological disorder affecting billions worldwide. While not life-threatening, migraine patients experience significant unmet needs in diagnosis and management. Addressing these challenges could result in improvement of patient outcomes and reduction of the socioeconomic burden migraine imposes on individuals, healthcare system and the society.

Objective

This survey aimed to capture in Greece the perspective of medical experts (neurologists) specializing in migraine management regarding the socioeconomic burden of migraine and the unmet needs in diagnosis and treatment.

Methods

An online Delphi-based survey was conducted with 13 neurologists, experts in migraine. The survey consisted of 55 statements derived from literature research, regarding the burden of disease, diagnosis, treatment and unmet needs. Participants' level of agreement for each statement was measured through a 5-point Likert scale ("Strongly Agree," "Agree," "Neither Agree nor Disagree," "Disagree" and "Strongly Disagree"). Three rounds of voting were conducted to achieve consensus. The consensus threshold was set at 70% of responses, focusing on "Strongly Agree"/ "Agree" or "Disagree"/ "Strongly Disagree."

Results

Most experts agreed on statements emphasizing on financial and social impact of the disease and its epidemiology. However, consensus was not reached on statements concerning patient preferences for treatment administration, treatment adherence, opioid use, and frequency of visits to neurologists. Consensus was reached on the need for better healthcare professional training and the development of effective, safe treatments.

Conclusion

This survey highlighted the challenges of prompt diagnosis and effective management of migraine. Addressing these needs requires patient-centered approaches, enhanced healthcare-provider training, tailored therapeutic interventions, and advanced communication platforms.

Anatomical and physiological contributions of nasal turbinate vessels and lymphatics to the pathogenesis of nasal congestion in recurrent headaches: a pilot study

Introduction

The aim of this study was to determine if specific anatomical changes were present in patients with recurrent headaches including patients with chronic migraines, chronic tension-type headaches, and daily persistent headaches. A retrospective study of 200 patients was performed to evaluate the potential of measuring the amount of nasal blood pool activity (nasal congestion) as a predictive marker for recurrent headaches.

Methods

A cohort analysis was performed involving patients who had been referred to the Nuclear Medicine Clinic over a 3-year period for whole-body blood pool scans. The scans were evaluated by region of interest (ROI) analysis of nasal and heart max pixel count ratios (NHMRs) to determine an association between nasal blood pooling activity and recurrent headaches at the time of the initial scan and in follow-up evaluations over a period of 3-6 years.

Results

Significantly greater NHMRs were observed in 122 patients with chronic headaches at the time of referral for their initial whole-body blood pool scan when compared with those patients without recurrent headaches (p = 0.004; OR 10.5; 95% CI 2.22-56.7). An additional 15 patients, for a total of 137, developed recurrent headaches following their initial scan and before their follow-up evaluation. NHMRs were also significantly increased in the additional patients when compared to those without recurrent headaches (p = 0.004; OR 12.3; 95% CI 2.34-75.5).

Conclusion

Patients with recurrent headaches have significantly increased nasal activity as observed on 99mTc-MDP whole-body blood pool scans, supporting the hypothesis that nasal lymphatic dysfunction plays a role in the etiology of recurrent headaches. This research highlights a novel diagnostic use of the whole-body blood pool scan for the assessment of nasal turbinate vasodilation as well as a possible new target for the treatment of recurrent headaches.

Assessment of Relationship Between Dietary Factors, Socioeconomic Factors, Behavioral Factors, Physical Measurement, and Risk of Migraine: A Univariable and Multivariable Mendelian Randomization Study

OBJECTIVE

Although numerous studies have identified associations between socioeconomic, behavioral, dietary, and physical factors and migraine, the causal nature of these relationships has yet to be adequately established.

MATERIALS AND METHODS

We utilized 2-sample Mendelian randomization (MR) to elucidate the causal associations of 28 distinct traits for socioeconomic factors, behavioral factors, dietary factors, and physical measurement with migraine. In the univariable MR analysis, the inverse-variance weighted method served as the primary analytic approach. Robustness checks included the Cochran Q test, Egger intercept test, and leave-one-out analysis. A multivariable MR analysis framework was utilized to assess the direct causal impacts of these traits on migraine risk.

RESULTS

The univariable MR analysis analysis revealed that genetic predispositions to higher coffee intake (Odds Ratio (OR) = 0.547; 95% CI = 0.359-0.834; P = 0.005), greater oily fish intake (OR = 0.556; 95% CI = 0.394-0.785; P = 0.001), and higher educational attainment (OR = 0.916; 95% CI = 0.884-0.949; P < 0.001) were associated with reduced migraine risk. In contrast, predispositions to higher poultry intake (OR = 4.690; 95% CI = 1.377-15.977; P = 0.013) and longer mobile phone use (OR = 1.526; 95% CI = 1.080-2.157; P = 0.017) correlated with increased risk. These associations remained consistent in the multivariable MR analysis after adjusting for stroke and particulate matter air pollution.

CONCLUSIONS

Our study robustly supports the significant causal roles of specific socioeconomic, behavioral, and dietary factors with physical measurement in the development of migraine. Notably, coffee intake, oily fish intake, and educational attainment appear protective, whereas poultry intake and extensive mobile phone use elevate risk. These insights pave the way for developing targeted preventive strategies for migraine.

Anxiety Disorders, Anxious Symptomology and Related Behaviors Associated With Migraine: A Narrative Review of Prevalence and Impact

PURPOSE OF REVIEW

The purpose of this study was to review the literature on the relationship between migraine, anxiety and related disorders, anxious symptomology and related behaviors.

RECENT FINDINGS

Generalized anxiety, other anxious disorders and migraine are comorbid. In addition, anxious symptomology and behaviors are common in people with migraine even if they do not meet diagnostic criteria or threshold. Anxiety including diagnosed disorders such as generalized anxiety, phobias, panic disorder, as well as behaviors such as catastrophizing, avoidance behaviors, and higher fear of headache/migraine or anxiety sensitivity are comorbid and/or common in migraine. Anxiety is associated with negative outcomes such as migraine progression, medication overuse, stigma and migraine-related disability. The association between migraine, anxiety, and fear and avoidance behaviors has an extensive empirical basis. Awareness of the high prevalence of comorbidity and symptomology as well as the negative outcomes associated with anxiety and related symptoms and behaviors is important in the comprehensive management of people with migraine. Better understanding the relationship between migraine and anxiety symptoms and behaviors and their effects on outcomes is essential to provide more effective treatment for people with migraine. The review emphasizes the necessity of screening and more comprehensive evaluation in patients with migraine using psychological diagnostic tools. Thus, prevention and management of anxiety, fear, and anxiety-related behaviors in the context of migraine management may be considered an essential treatment goal and strategies may include non-pharmacological and pharmacological approaches.

Early Improvements With Atogepant for the Preventive Treatment of Migraine: Results From 3 Randomized Phase 3 Trials

BACKGROUND AND OBJECTIVES

Three phase 3 trials demonstrated the efficacy and safety of atogepant in episodic migraine (EM) and chronic migraine (CM) across 12-week treatment periods. This analysis evaluates improvements in efficacy and functional outcomes in the first 4 weeks of treatment with the oral calcitonin gene-related peptide receptor antagonist, atogepant, for the preventive treatment of migraine.

METHODS

ADVANCE, ELEVATE, and PROGRESS were phase 3, multicenter, randomized, double-blind, placebo-controlled 12-week trials. ADVANCE and ELEVATE included participants aged 18-80 years with >1 year history of EM and 4-14 monthly migraine days (MMDs). ELEVATE required previous treatment failures to 2-4 classes of oral preventives. PROGRESS included participants aged 18-80 years with >1 year history of CM, ≥15 monthly headache days, and ≥8 MMDs. This analysis reports the atogepant 60 mg once daily (QD) and placebo treatment arms. Outcomes included efficacy endpoints (reporting a migraine day on day 1, change from baseline in weekly migraine days [WMDs] at weeks 1-4, and in MMDs in the first 4 weeks) and functional endpoints evaluated by the Activity Impairment in Migraine-Diary (AIM-D) at weeks 1-4 and the European Quality-of-Life 5-Dimension 5-Level (EQ-5D-5L) at weeks 1-2 and 4.

RESULTS

The modified intent-to-treat population included the ADVANCE (atogepant, n = 222; placebo, n = 214), ELEVATE (atogepant, n = 151; placebo, n = 154), and PROGRESS (atogepant, n = 256; placebo, n = 246) studies. Atogepant-treated participants had greater reductions in the proportion of participants with a migraine day on day 1. The odds ratio compared with placebo was 0.39 (95% CI 0.23-0.67; p = 0.0006) in ADVANCE, 0.53 (95% CI 0.29-0.94, p = 0.031) in ELEVATE, and 0.63 (95% CI 0.43-0.93, p = 0.021) in PROGRESS. Atogepant treatment reduced WMDs at weeks 1-4 and MMDs in the first 4 weeks, and improved AIM-D and EQ-5D-5L at all assessed timepoints for weeks 1-4 compared with placebo.

DISCUSSIONS

Atogepant 60 mg QD demonstrated superiority to placebo in efficacy and functional measures in the first 4 weeks of treatment across 3 preventive studies, 2 in EM and 1 in CM.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03777059; NCT04740827; NCT03855137. Submitted: 12/13/2018; 02/02/2021; 02/25/2019. First patient enrolled: 12/14/2018; 03/05/2021; 03/11/2019 clinicaltrials.gov/ct2/show/NCT03777059. clinicaltrials.gov/ct2/show/NCT04740827 clinicaltrials.gov/ct2/show/NCT03855137.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that atogepant 60 mg QD reduces migraine frequency and improves functional outcomes within 4 weeks of initiation in patients with EM and patients with CM.

Carbon monoxide poisoning is associated with increased risk of migraine in the long term: a nationwide population-based cohort study

Objective

Carbon monoxide poisoning can cause migraine-like attacks. However, the association between carbon monoxide poisoning and the risk of migraine has not been thoroughly studied. This study aimed to investigate the long-term risk of migraine in patients with carbon monoxide poisoning.

Methods

This nationwide, population-based cohort study was conducted using the administrative database of the National Health Insurance Service of Korea from 2002 to 2021. Patients with carbon monoxide poisoning with at least one visit documented according to the International Classification of Diseases, 10th Revision code T58 were included. Patients were only included if they had the same diagnostic code at two or more outpatient clinic visits. The primary outcome of this study was the incidence of migraine after carbon monoxide poisoning.

Results

The overall risk of migraine was higher in the carbon monoxide poisoning group regardless of age, sex, or use of hyperbaric oxygen therapy (adjusted hazard ratio, 1.37; 95% confidence interval, 1.28-1.48). The carbon monoxide poisoning group had a persistently higher cumulative incidence of migraine during the observation period than the control group.

Conclusion

Carbon monoxide poisoning was associated with an increased overall risk of developing migraine during long-term follow-up.

The epidemiology and unmet need of migraine in five european countries: results from the national health and wellness survey

BACKGROUND

Despite the high global prevalence, burden, and direct and indicated costs, migraines are often under-diagnosed and undertreated. Understanding the prevalence of migraine and unmet needs is crucial for improving diagnosis and treatment across Europe (EU) countries; however, real-world studies are limited.

METHODS

This retrospective cross-sectional survey utilized weighted patient-reported data from the 2020 National Health and Wellness Survey (NHWS) in five EU (5EU) countries (France, Germany, United Kingdom [UK], Italy, and Spain). The survey included adults aged ≥ 18 years who self-reported experiencing migraines in the past 12 months and had a physician's diagnosis. The survey assessed migraine prevalence by age and sex. Other measures included migraine characteristics, disability assessment, migraine frequency (monthly migraine days [MMDs] and monthly headache days [MHDs], menstrually-related migraine, treatment patterns, and provider characteristics.

RESULTS

The study included 7,311 respondents with diagnosed migraines, representing an estimated 30.5 million adults with a weighted prevalence of 11.5% in the 5EU. Spain had the highest prevalence (14.0%), followed by Italy, France, UK, and Germany. Migraine prevalence was highest in the age group of 30-39 years, and females had nearly twice the prevalence compared to males. About 56% of respondents reported disability due to migraines, with highest percentage reported in Germany (66.0%). About 46% of female respondents reported experiencing menstrually-related migraines. One-fourth of the study respondents reported > 4 MMDs and 56.2% reported > 4 MHD. Current treatment patterns revealed that 79.7% of respondents were receiving some form of migraine treatment, with non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and triptans being the most commonly reported prescription medications. Primary care physicians (PCPs) were the most common providers diagnosing migraines, followed by neurologists.

CONCLUSIONS

In the 5EU, one-fourth of diagnosed respondents reported > 4 MMDs, and 56.2% reported > 4 MHDs. Nearly half of females experienced menstrually-related migraines. Although most patients reported taking medication for migraine, severe disability and medication overuse were observed. PCPs were the main treatment providers, highlighting the need for improved expertise and referrals to specialists. Further research is required for a better understanding of the disparities between migraine frequency and treatment approaches.

Effect of erenumab on the reversion from chronic migraine to episodic migraine in an Asian population: A post hoc analysis of the DRAGON study

BACKGROUND

Erenumab is a fully human monoclonal antibody that selectively targets the calcitonin gene-related peptide receptor. It has been proven to be safe and efficacious in patients with episodic migraine (EM) and chronic migraine (CM) as demonstrated in phase 2 and 3 clinical trials including patients from Europe, Japan, and the United States. Reversion from CM to EM, as indicated by a reduction in the frequency of headache days, is an important indicator for efficacy outcome, though it has not been analyzed widely in patients with CM to date.

OBJECTIVE

Primary results of the DRAGON study demonstrated the efficacy and safety of erenumab in patients with CM from China and other Asian countries. This post hoc analysis evaluated the rate of reversion from CM to EM in the overall population and in subgroups of patients defined by baseline demographic and clinical characteristics (age, body mass index, gender, prior preventive treatment failure, medication overuse status, and disease duration).

METHODS

Reversion from CM to EM was defined as a reduction in headache frequency to < 45 headache days over the 12 weeks of the double-blind treatment period. In addition, migraine-related disability and disease impact on functional impairment were assessed within each treatment group in reverters and non-reverters using the Headache Impact Test-6 (HIT-6), Migraine Physical Function Impact Diary (MPFID), and modified Migraine Disability Assessment (mMIDAS).

RESULTS

Overall, 557 patients with CM were randomized to monthly erenumab 70 mg (n = 279) or placebo (n = 278), of whom 52.3% (146 of 279) treated with erenumab reverted from CM to EM compared to 41.0% (114 of 278) in the placebo group (odds ratio [OR] 1.59, 95% confidence interval: 1.1-2.2; p = 0.007). Treatment with erenumab resulted in a greater mean change (standard error) from baseline in the HIT-6 total score for reverters versus non-reverters compared to placebo (erenumab: -9.5 [0.6] vs. -5.1 [0.5]; placebo: -8.9 [0.7] vs. -4.9 [0.5]). A similar pattern was observed for mMIDAS score in erenumab treatment groups versus placebo (erenumab: -22.1 [1.2] vs. -6.3 [1.8]; placebo: -19.9 [1.3] vs. -7.9 [1.6]). Substantial improvements were reported in MPFID-Physical Impairment (PI) and Everyday Activities (EA) scores in reverters versus non-reverters in erenumab treatment groups (MPFID-PI: -5.9 [0.3] vs. -1.9 [0.6]; MPFID-EA: -7.9 [0.4] vs. -3.4 [0.6]) and in placebo (MPFID-PI: -5.4 [0.4] vs. -1.0 [0.5]; MPFID-EA: -7.1 [0.5] vs. -3.2 [0.5]).

CONCLUSIONS

This analysis demonstrated that a greater proportion of patients treated with erenumab reverted from CM to EM compared to patients treated with placebo. The reversion from CM to EM was reflected by the greater improvements in patient-reported outcomes in the erenumab group.

Relative frequency, characteristics, and disease burden of patients with migraine unsuitable for triptan treatment: A systematic literature review

OBJECTIVE

This review was conducted to systematically identify evidence characterizing patients with migraine who are unsuitable for triptans.

BACKGROUND

Triptans are not suitable as first-line treatment for all patients with migraine due to contraindications, lack of efficacy, and/or poor tolerability. However, there is debate about the frequency and characteristics of these patients and the burden they experience.

METHODS

MEDLINE, Embase, and conference abstracts (2011-2022) were reviewed for evidence on patients with migraine unsuitable for triptans for any reason. Data from publications describing the frequency and characteristics of this group, as well as the clinical, humanistic, or economic burden of disease in this population, were extracted.

RESULTS

Of 1460 records screened, 29 publications met inclusion criteria. Persistence with triptans was low; 51%-66% of patients starting a new triptan did not refill it, and 43%-100% discontinued their initial triptan over 2 years. In one study, 14% of patients with migraine reported prior discontinuation/failure of ≥ 2 triptans due to inadequate efficacy or poor tolerability. Up to 15% of patients with migraine had triptan contraindications, and ≥ 20% of patients receiving triptans had contraindications. In four studies, 10%-44% of patients who tried triptans had insufficient response, although definitions varied. Patients who achieved a sufficient response typically did so with their first triptan; few became responders with additional triptans. Of patients who did not respond to one to two triptans and received another, 45% were dissatisfied with the final triptan. Approximately half of patients who tried two to three triptans had an insufficient response. Greater disability, impact of disease, and depression were reported in triptan discontinuers compared to those with sustained use. Worse quality of life scores and utility values were reported in triptan insufficient versus sufficient responders, as were greater migraine-related costs, work impairment, and health-care resource utilization.

CONCLUSION

The total population of patients unsuitable for triptans is uncertain, but the literature highlights a large group who cannot or do not persist with triptans, and current evidence suggests a high burden in this population and an unmet need for new therapeutic options. Further research is needed to determine the frequency of unsuitability for triptans more precisely and to assess the associated burden.

Auditory evoked brainstem responses and medial olivocochlear efferent system in migraine patients with phonophobia

OBJECTIVE

This study aims to investigate Auditory Evoked Brainstem Responses (ABR) and Distortion Product Otoacoustic Emission (DPOAE) suppression in migraine patients with and without phonophobia.

METHODS

Thirty-two migraine patients with normal hearing and 30 healthy individuals were included in the study. Migraine characteristics and phonophobia status of migraine patients were noted. The patients were divided into two groups according to their phonophobia status. All participants underwent ABR, DPOAE and DPOAE suppression.

RESULTS

Migraine patients had less DPOAE suppression (1481 and 2222 hz) and shorter ABR wave latencies compared to the control group (p < 0.05). Twelve (37.5%) of the migraine patients did not have phonophobia, and 20 (62.5%) had phonophobia. Phonophobia was not found to affect DPOAE suppression (p > 0.05). However, ABR wave I and V latencies in migraine patients with phonophobia were shorter than in healthy individuals (p < 0.05).

CONCLUSION

There are changes in the auditory evoked brainstem responses and medial olivocochlear efferent system of migraine patients. While phonophobia in migraine patients does not affect the medial olivocochlear efferent system, it may affect auditory evoked brainstem responses.

Migraine and cognitive dysfunction: a narrative review

The association between migraine and cognitive function has been studied during the last decade, however, this relationship is not well established. As migraine prevalence is highest between the ages of 30-40, aligning with some of our most productive years, we must understand cognitive changes within this disorder. Cognitive impairment potentially limits social and professional interactions, thus negatively impacting quality of life. Therefore, we will review the relationship between prevalent migraine and cognition. Cognitive dysfunction has been reported to be the second largest cause of disability, after pain, in migraine patients. While subjective patient reports on cognition consistently describe impairment, findings for objective neuropsychological assessments vary. Many studies report worse cognitive performance in the ictal phase compared to controls, which can persist into the postictal period, although whether this continues in the interictal period has been understudied. There is limited consensus as to whether cognition differs in migraine with aura versus migraine without aura, and while many studies do support cognitive impairment in chronic migraine, it remains uncertain as to whether this is more debilitating than the cognitive difficulties experienced by those with episodic migraine. To date, objective assessment of neurological abnormalities that may underlie cognitive impairment through neuroimaging has been underutilized. There is limited consensus as to whether cognitive impairment is a characteristic specific to migraine, whether it is driven by a combination of factors including co-morbidities such as anxiety, depression, or vascular dysfunction, treatment, or whether it is a more general characteristic of pain disorders. Overall, increasing numbers of studies support cognitive impairment in migraine patients. Future studies should consider longitudinal study designs to assess cognition across different migraine phases and subtypes of the disorder, including migraine with aura and chronic migraine, as well as controlling for important confounders such as treatment use.

Can Clinical, Psychophysical or Psychological Variables Help in Discriminating Women with Migraines from a Tertiary Center? A Diagnostic Accuracy Study

Background: Migraine diagnosis is mainly clinically based on symptomatology. The objectives of this study were (1) to determine the ability of pain thresholds to differentiate between women with and without migraines and (2) to determine the ability of clinical, psychological and psychophysical variables to differentiate between women with episodic and chronic migraines. A diagnostic accuracy study was conducted. Methods: Pressure-pain thresholds (PPTs) at one trigeminal (temporalis muscle) and one extra-trigeminal (cervical spine) and two distant-pain free (second metacarpal and tibialis anterior muscle) areas, as well as dynamic pain thresholds (DPTs), were bilaterally assessed in 100 women with migraines, recruited from tertiary hospitals (50% episodic, 50% chronic), and 50 comparable women without headaches. Migraine pain features (headache diary), migraine-associated burden (HDI), anxiety and depressive levels (HADS) and state (STAI-S)-trait (STAI-T) anxiety were also evaluated. The area under the receiver operating characteristic (ROC) curve, with optimal cut-off points, as well as the sensitivity, specificity and positive/negative likelihood ratios (LR) for each variable, were calculated. The women with migraines showed lower PPTs and DPTs than those without migraines. Results: The women with chronic migraines showed lower PPTs in the temporalis muscle than the women with episodic migraines. No clinical, psychological or psychophysical variables exhibited acceptable ROC values (≥0.7) for differentiating between women with and without migraines or between women with episodic and chronic migraines. Conclusions: Although the women with migraines had widespread pressure-pain hyperalgesia, neither the clinical, psychological nor psychophysical (pain threshold) variable exhibited the proper diagnostic accuracy to distinguish between women with and without migraines or between women with episodic and chronic migraines. New studies should clarify the clinical relevance of the findings of the current study.

Review on the Burden of Episodic Migraine and Utilization of Patient Reported Outcome Measures

PURPOSE OF REVIEW

Migraine affects a large portion of the world's population. Migraine encompasses a broad range of symptoms, with broad reaching ramifications in the form of Health-Related Quality of Life (HRQoL) factors. In our review we sought to understand the aspects encompassing the burden of disease on both an individual and population level. Furthermore, we reviewed the development and incorporation of Patient Reported Outcome Measures (PROM), questionnaires that assess HRQoL in real time, in how they have been incorporated in clinical research up to now and how they can be utilized in clinical practice moving forward.

RECENT FINDINGS

It has been shown that there is much heterogeneity within the field in PROM development processes as well as their utilization in episodic migraine (EM) clinical trials. Furthermore, they are inconsistently used in clinical practice. Among the most commonly used PROMs, the MSQv2.1 is among the most valid and reliable. Beyond that, it also shows promise to help in guidance of clinical management of migraine.

Real-World Experience of Erenumab in Patients with Migraine in Germany: The SPECTRE Study

INTRODUCTION

To provide real-world insights into migraine patient population in Germany treated with erenumab, focusing on the prescription patterns and reasons for the initial dosage choice.

METHODS

SPECTRE was an observational, non-interventional, multicenter, open-label, single-arm study in patients treated with erenumab according to approved local dose and guidelines. The study enrolled adult patients (n = 571; Germany: 105 sites) with migraine who had received erenumab for not more than 3 months before the start of the study.

RESULTS

The mean (standard deviation) patient age was 45.0 (12.3) years, and most patients were female (89.0%), Caucasian (97.6%), and non-smokers (85.1%). The starting dose of erenumab was 70 mg in 68.5% of patients and 140 mg in 31.5%. The proportion of patients with 140 mg as the starting dose was the highest (43.5%) in those aged 30-40 years. The most common reason for starting a higher dose of erenumab 140 mg was severity of migraine (47.4%). During the observational period, the proportion of patients taking erenumab 140 mg increased to 64.6% (visit 5; V5) after 12 months. Due to attrition of patients towards the end of the study (V9: 90 participants), data at V9 must be interpreted with caution. At least one dose change was performed in 45.3% of patients (i.e., erenumab 70 to 140 mg or 140 to 70 mg), 21.2% of patients attempted at least once to discontinue treatment (i.e., period with erenumab discontinuation and no other antibody treatment for migraine prevention), and 15.3% discontinued erenumab treatment, mainly because of no or insufficient treatment response (13.5%). The mean time until the first omission attempt was 332.3 (range 37-633) days. Constipation (12.1%) was the most frequently reported adverse event, in line with the summary of product characteristics (SmPC) of erenumab.

CONCLUSION

Most patients with migraine were prescribed erenumab 70 mg as the starting dose. No new safety signals were observed for erenumab versus the previous trials.

The incremental burden and healthcare resource utilization among people with migraine in Europe: Insights from the 2020 European National Health and Wellness Survey

BACKGROUND

Despite the high prevalence of migraine in Europe, there is limited research on the burden among people with migraine.

METHODS

This cross-sectional survey used patient-reported data from the 2020 European National Health and Wellness Survey in France, Germany, Italy, Spain, and the United Kingdom. The study assessed the sociodemographic characteristics, health-related quality of life, depression, work productivity and activity impairment, and healthcare resource utilization among matched samples of people with diagnosed migraine (n = 3985) and compared to a matched cohort without migraine (n = 7970). The study also analyzed the burden across migraine subgroups stratified by the number of migraine headache days.

RESULTS

Lower health-related quality of life, higher depression, increased work productivity and activity impairment, and higher healthcare resource utilization were reported among people with migraine and ≥1 migraine headache days compared to matched people without migraine (all p < 0.001). Additionally, the incremental burden was also observed across migraine subgroups (1-3, 4-7, 8-14, and ≥15 migraine headache days) irrespective of the use of prescription medication compared to the matched controls without migraine.

CONCLUSION

Migraine sufferers with ≥1 migraine headache days experienced worse productivity, lower quality of life, depression, and increased healthcare resource utilization than those without migraine, emphasizing the need for effective management strategies.

Intranasal zavegepant for the acute treatment of migraine

INTRODUCTION

Migraine is a highly prevalent chronic, inherited neurological condition of the brain which carries a significant level of disability. Despite advances, there is an unmet need for more effective therapies.

AREAS COVERED

Zavegepant nasal spray is a recent therapeutic option which acts as a calcitonin gene-related peptide receptor antagonist. The objective is to review the efficacy, safety, and additional results of the most recent trials investigating intranasal zavegepant for the acute treatment of migraine with or without aura. The authors searched PubMed using the keywords 'zavegepant,' 'Zavzpret,' 'migraine,' 'calcitonin gene-related peptide,' 'CGRP receptor antagonists.' This article covers Phase 1, Phase 2/3, and Phase 3 randomized, double-blind, placebo-controlled trials to evaluate the efficacy of intranasal zavegepant for treatment of acute migraine attacks.

EXPERT OPINION

Intranasal zavegepant is an efficacious, safe, and tolerable anti-migraine drug based on clinical trials and clinical experience. It is especially useful for patients who experience attacks of sudden onset, those with nausea or vomiting, or a high cardiovascular risk burden. Dysgeusia was common; future studies are needed to better characterize this adverse event. Head-to-head studies are lacking with other migraine-specific therapies; the decision to treat should be patient-centered, with attack-specific characteristics in mind.

Spinal manipulations for migraine: an updated systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

This update of a systematic review evaluates the effectiveness of spinal manipulations as a treatment for migraine headaches.

BACKGROUND

Spinal manipulation therapy (SMT) is sometimes used to treat migraine headaches; however, the biological plausibility and safety of SMT have repeatedly been questioned.

METHODS

Amed, Embase, MEDLINE, CINAHL, Mantis, Index to Chiropractic Literature, and Cochrane Central were searched from inception to September 2023. Randomized clinical trials (RCTs) investigating spinal manipulations (performed by various healthcare professionals including physiotherapists, osteopaths, and chiropractors) for treating migraine headaches in human subjects were considered. Other types of manipulative therapy, i.e., cranial, visceral, and soft tissue were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.

RESULTS

Three more RCTs were published since our first review; amounting to a total of 6 studies with 645 migraineurs meeting the inclusion criteria. Meta-analysis of six trials showed that, compared with various controls (placebo, drug therapy, usual care), SMT (with or without usual care) has no effect on migraine intensity/severity measured with a range of instruments (standardized mean difference [SMD] - 0.22, 95% confidence intervals [CI] - 0.65 to 0.21, very low certainty evidence), migraine duration (SMD - 0.10; 95% CI - 0.33 to 0.12, 4 trials, low certainty evidence), or emotional quality of life (SMD - 14.47; 95% CI - 31.59 to 2.66, 2 trials, low certainty evidence) at post-intervention. A meta-analysis of two trials showed that compared with various controls, SMT (with or without usual care) increased the risk of AEs (risk ratio [RR] 2.06; 95% CI 1.24 to 3.41, numbers needed to harm = 6; very low certainty evidence). The main reasons for downgrading the evidence were study limitations (studies judged to be at an unclear or high risk of bias), inconsistency (for pain intensity/severity), imprecision (small sizes and wide confidence intervals around effect estimates) and indirectness (methodological and clinical heterogeneity of populations, interventions, and comparators).

CONCLUSIONS

The effectiveness of SMT for the treatment of migraines remains unproven. Future, larger, more rigorous, and independently conducted studies might reduce the existing uncertainties.

Nutrigenomics and neurological disorders: exploring diet-brain interactions for cognitive health

This review article investigates the intricate relationship between nutrigenomics and neurological disorders, highlighting how genetic variations affect an individual's response to nutrients. The study delves into the role of diet-related oxidative stress and the gut-brain axis in the progression and management of brain disorders such as Parkinson's disease, Alzheimer's disease, epilepsy, stroke, migraines, and depression. The review encompasses various clinical trials and introduces new trends and techniques, including omics and artificial intelligence, in identifying and managing neurological disorders. The main findings emphasize that personalized diet recommendations, tailored to an individual's genetic makeup, can significantly improve cognitive health and manage neurological conditions. The study concludes that further research in the field of nutrigenomics is essential to advancing personalized nutrition strategies for better neurological functioning, ultimately linking diet, genes, and brain health.

Plasma pQTL and brain eQTL integration identifies PNKP as a therapeutic target and reveals mechanistic insights into migraine pathophysiology

BACKGROUND

Migraine is a prevalent neurological disorder affecting 14.1% of the global population. Despite advances in genetic research, further investigation is needed to identify therapeutic targets and better understand its mechanisms. In this study, we aimed to identify drug targets and explore the relationships between gene expression, protein levels, and migraine pathophysiology.

METHODS

We utilized cis-pQTL data from deCODE Genetics, combined with migraine GWAS data from the GERA + UKB cohort as the discovery cohort and the FinnGen R10 cohort as the replication cohort. SMR and MR analyses identified migraine-associated protein loci. Brain eQTL data from GTEx v8 and BrainMeta v2 were used to explore causal relationships between gene expression, protein levels, and migraine risk. Mediation analysis assessed the role of metabolites, and PheWAS evaluated potential side effects.

RESULTS

Four loci were identified: PNKP, MRVI1, CALCB, and INPP5B. PNKP and MRVI1 showed a high level of evidence and opposing effects at the gene and protein levels. PNKP gene expression in certain brain regions was protective against migraine, while its plasma protein levels were positively associated with migraine risk. MRVI1 showed protective effects at the protein level but had the opposite effect at the gene expression level. Mediation analysis revealed that the glutamate to pyruvate ratio and 3-CMPFP mediated PNKP's effects on migraine. PheWAS indicated associations between PNKP and body composition traits, suggesting drug safety considerations.

CONCLUSION

PNKP and MRVI1 exhibit dual mechanisms of action at the gene and protein levels, potentially involving distinct mechanistic pathways. Among them, PNKP emerges as a promising drug target for migraine treatment, supported by multi-layered validation.

Safety and tolerability of ubrogepant for the acute treatment of migraine in participants taking atogepant for the preventive treatment of episodic migraine: Results from the TANDEM study

OBJECTIVE

To evaluate the safety and tolerability of ubrogepant for the acute treatment of migraine in participants taking atogepant for the preventive treatment of episodic migraine (EM).

BACKGROUND

Atogepant is an oral calcitonin gene-related peptide (CGRP) receptor antagonist approved for the preventive treatment of migraine in adults and ubrogepant is an oral CGRP receptor antagonist approved for the acute treatment of migraine in adults, with or without aura. The safety and tolerability of the concomitant use of ubrogepant and atogepant have not been previously evaluated in a clinical setting.

METHODS

The TANDEM study, a phase 4, two-period, multicenter, open-label study conducted in the United States, enrolled adults with migraine, with or without aura, and <15 headache days/month. In Treatment Period 1, participants took atogepant 60 mg once daily (QD) for 12 weeks and their own non-gepant acute headache medication for breakthrough migraine attacks. In Treatment Period 2, participants continued taking atogepant 60 mg QD and ubrogepant 100 mg was taken as needed (PRN) for the treatment of breakthrough migraine attacks (up to eight per 4-week interval) for 12 weeks. In Treatment Period 2, an optional second ubrogepant dose or the participant's own acute medication could be used to rescue headaches that did not resolve within 2-24 h post initial ubrogepant dose. The primary objective evaluated the safety and tolerability of the concomitant use of ubrogepant and atogepant.

RESULTS

Of 263 participants enrolled, 262 were treated in Treatment Period 1 (Safety Population 1) and 218 continued and were treated in Treatment Period 2 (Safety Population 2). The mean (standard deviation) number of ubrogepant use days in Treatment Period 2 was 6.6 (5.03) over the 12 weeks. In Treatment Periods 1 and 2, 49.6% and 43.1% of participants experienced a treatment-emergent adverse event (TEAE), respectively. The most common TEAEs (≥5%) in Treatment Period 1 and Treatment Period 2 were COVID-19 (8.4%, 3.2%), fatigue (6.5%, 1.4%), nausea (6.1%, 0.9%), decreased appetite (5.7%, 0.9%), and constipation (5.3%, 0.9%). In Treatment Period 2, no increase in the incidence and types of TEAEs in relation to the number of ubrogepant use days or doses taken were identified. During the whole treatment period, 9.9% of participants discontinued atogepant or ubrogepant treatment due to TEAEs. There was one serious TEAE in Treatment Period 1 (ureterolithiasis) and one in Treatment Period 2 (cervical myelopathy), and both were considered not related to study treatment by the study investigators.

CONCLUSION

The use of atogepant 60 mg QD for the preventive treatment of EM and ubrogepant 100 mg PRN for the acute treatment of migraine over the 12-week open-label concomitant use treatment period was safe and well tolerated. The overall safety results were consistent with the known safety profiles of atogepant and ubrogepant when used alone and no new safety signals were identified.

A three-classification model for identifying migraine with right-to-left shunt using lateralization of functional connectivity and brain network topology: a resting-state fMRI study

Introduction

Right-to-left shunting has been significantly associated with migraine, although the neural mechanisms remain complex and not fully elucidated. The aim of this study was to investigate the variability of brain asymmetry in individuals with migraine with right-to-left shunting, migraine without right-to-left shunting and normal controls using resting-state fMRI technology and to construct a three-classification model.

Methods

Firstly, asymmetries in functional connectivity and brain network topology were quantified to laterality indices. Secondly, the laterality indices were employed to construct a three-classification model using decision tree and random forest algorithms. Ultimately, through a feature score analysis, the key brain regions that contributed significantly to the classification were extracted, and the associations between these brain regions and clinical features were investigated.

Results

Our experimental results showed that the initial classification accuracy reached 0.8961. Subsequently, validation using an independent sample set resulted in a classification accuracy of 0.8874. Further, after expanding the samples by the segmentation strategy, the classification accuracies were improved to 0.9103 and 0.9099. Additionally, the third sample set yielded a classification accuracy of 0.8745. Finally, 9 pivotal brain regions were identified and distributed in the default network, the control network, the visual network, the limbic network, the somatomotor network and the salience/ventral attention network.

Discussion

The results revealed distinct lateralization features in the brains of the three groups, which were closely linked to migraine and right-to-left shunting symptoms and could serve as potential imaging biomarkers for clinical diagnosis. Our findings enhanced our understanding of migraine and right-to-left shunting mechanisms and offered insights into assisting clinical diagnosis.

Effectiveness of fremanezumab treatment in patients with migraine headache

OBJECTIVE

To evaluate the efficacy and safety of fremanezumab for migraine prevention.

DESIGN

Retrospective, single-center, real-world study.

SETTING

Regional tertiary headache center in Japan.

SUBJECTS

Adult individuals with migraine (n = 165, male = 17, female = 148; average age = 45.5 ± 16.0 years) who received fremanezumab between September 2021 and August 2022.

METHODS

Fremanezumab was administered subcutaneously at a monthly dose of 225 mg or quarterly dose of 675 mg based on patient preferences. Patients received fremanezumab treatment for up to 1 year unless it was discontinued. Monthly data were collected on migraine days, headache days, and days requiring acute medication.

RESULTS

Of the 165 patients, 125 (75.7%) received fremanezumab as their first anti-calcitonin gene-related peptide-related antibody drug. Significant reductions in monthly migraine days, headache days, and days requiring acute medication were observed in those with episodic and chronic migraines. The baseline monthly headache days was 8.1 ± 4.0 in the episodic migraine group, which reduced to 6.1 ± 4.8, 5.8 ± 4.4, 4.7 ± 3.6, and 4.6 ± 3.3 days at 1, 3, 6, and 12 months, respectively; in the chronic migraine group, the baseline monthly headache days was 20.9 ± 6.1, which reduced to 17.0 ± 8.9, 15.0 ± 9.2, 13.0 ± 7.7, and 12.0 ± 9.1 days at 1, 3, 6, and 12 months, respectively. Treatment benefits were enhanced after 6 months of administering fremanezumab in the chronic migraine group.

CONCLUSIONS

In this real-world study of patients with migraine, fremanezumab appears to be effective and safe. Further studies are required to identify additional predictors of treatment success and failure with fremanezumab.

Migraine Headache and Patent Foramen Ovale: Observational Studies, the Randomized Clinical Trials, and the GORE RELIEF Clinical Study

The pathophysiology of migraine remains poorly understood. Like most migraine preventive therapies, patent foramen ovale (PFO) closure was never intended for the treatment of migraine. After closure of PFO for other reasons, migraine symptom reduction/elimination was noted in some patients. Subsequent small trials failed to prove its benefit. There is significant evidence suggesting a platelet-mediated mechanism linking migraines to PFO. The GORE RELIEF Clinical Study is a randomized, blinded, placebo- and sham-controlled trial, currently enrolling. The study design is meant to optimize patient selection using thienopyridine responsiveness as an inclusion criterion.

Research trends and hotspots in clinical trials of migraine in the past 20 years: bibliometric analysis

Background

Migraine is a widespread, recurrent primary headache disorder primarily characterized by severe pulsatile headache, typically on one or both sides. It is often accompanied by nausea, vomiting, and hypersensitivity to sound and light. Despite the availability of multiple drugs for migraine management, the condition often becomes chronic due to untimely or irrational drug use, significantly distressing patients and increasing the burden on families and society. Over the past two decades, numerous clinical studies on migraine have been published. This study aimed to provide a comprehensive summary of the current status and trends of migraine clinical trials through bibliometric analysis.

Methods

We used visual network tools such as CiteSpace and VOSviewer to perform a knowledge graph analysis of publications related to migraine clinical trials extracted from the WoSCC.

Results

This study analyzed 1,129 articles published in 389 journals from 61 countries. The number of publications on migraine clinical trials has steadily increased from 2004 to 2023. The United States and Albert Einstein College of Medicine are the leading countries and institutions in this field, respectively. Richard B. Lipton is the most prolific author, making significant contributions to the research. The journal Headache has the highest number of publications and citations in this area. Keywords such as "efficacy," "RCT," "CGRP," "prophylaxis," "disability," "depression," "questionnaire," and "real-world effectiveness" received significant attention.

Conclusion

This study identified reliable research hotspots and provided directions for clinicians. The treatment of migraine continues to be challenging. Future trends may include continued growth in migraine classification, risk factor analysis, and comorbidity studies. Research on CGRP and epigenetics will advance the progress of precision medicine in the migraine field.

Efficacy and Tolerability of Erenumab and Topiramate for Prevention of Chronic Migraine: A Retrospective Cohort Study

Background and Objectives: Migraine is a chronic neurological disorder affecting approximately 14% of the global population. Beyond physical pain, migraines significantly impact individuals' quality of life, influencing education, employment, and income levels. Topiramate, a second-generation antiepileptic medication, has demonstrated notable efficacy in reducing the occurrence of chronic migraine. Over the past three decades, extensive research has implicated the neuropeptide calcitonin gene-related peptide (CGRP) in migraine pathogenesis. Erenumab, the first FDA-approved CGRP inhibitor, received approval in 2018. This study aims to compare the clinical efficacy of Erenumab and Topiramate for migraine prevention. Materials and Methods: We conducted a retrospective cohort study of adults with episodic or chronic migraine over a 12-month period, comparing Erenumab (n = 52) and Topiramate (n = 56). Outcomes assessed included changes in the Migraine Disability Assessment (MIDAS) scores from baseline over the last three months of treatment and the proportion of patients achieving a ≥50% reduction in MIDAS scores by the end of the study. Results: The Erenumab group showed significant improvement, with nearly 79% of patients achieving a 50% reduction in their MIDAS score, with a mean reduction of 3.76. Notably, only two patients (3.8.5) discontinued treatment due to adverse events. In contrast, the Topiramate group had over 15% of patients achieve a 50% reduction in MIDAS scores, with a mean reduction of 5.89, and a had discontinuation rate of 14.2% due to adverse events. Conclusions: Both Topiramate and Erenumab are effective for migraine prevention. However, Topiramate has lower tolerability and more side effects, while Erenumab offers better tolerability and safety at a higher cost. Treatment decisions should be individualized based on patient needs, efficacy, safety, and cost considerations.

The Evidence for Diet as a Treatment in Migraine-A Review

Background/objectives: The connection between diet and migraine has gained increasing attention in migraine research due to its potential relevance as part of migraine treatment. This study reviewed the current evidence on the use of diets or specific foods in the prevention of migraine. Methods: A PubMed search was performed with the keywords "diet and migraine" OR "brain-gut-axis and migraine". One author (KVN) screened titles, abstracts, and full-text articles and excluded or included them based on eligibility criteria. Results: A ketogenic diet and a "Dietary Approaches to Stop Hypertension" diet reduced attack duration (p < 0.002), frequency (p < 0.05), and severity (p < 0.01). The ketogenic diet also reduced monthly medication intake (p ≤ 0.05). A low-fat vegan diet mixed with an elimination diet reduced the attack duration (p < 0.01), frequency (p < 0.05), severity (p < 0.0001), and percentage of medicated headaches (p < 0.001). Elimination diet reduced attack duration (p < 0.05), frequency (p < 0.02), severity (p < 0.01), and medication intake (p < 0.002). Elimination diet with IgG-positive foods reduced attack frequency (p < 0.001), and total medication intake (p < 0.01). Gluten-free diet reduced frequency (p = 0.02) and severity (p = 0.013). Conclusions: Certain diets and food items may trigger attacks in some migraine patients, though the overall evidence supporting this is limited. Modifying a diet may reduce symptoms such as attack duration, frequency, severity, and medication intake. However, the included studies' small populations and diverse study designs make the results difficult to apply in clinical practise. Further high-quality, double-blinded, randomised controlled trials are necessary to confirm the association between diet and migraine.

Health-related quality of life among women and men living with migraine: a Canada-wide cross-sectional study

BACKGROUND

Migraine is a prevalent neurologic disorder that affects women more than men. Examining health-related quality of life (HRQoL) by gender can aid decision makers in prioritizing future treatment and prevention programs. We aimed to quantify HRQoL by different levels of migraine disability and by gender.

METHODS

As part of a Canada-wide cross-sectional study, we administered an online survey to employed adults who self-reported a diagnosis of migraine. Migraine disability level was assessed using the Migraine Disability Assessment questionnaire (MIDAS). MIDAS scores were used to categorize respondents as having little to no, mild, moderate, or severe level of migraine-related disability. Physical and mental component summary scores (PCS and MCS) and health utilities were derived from responses to the Veterans Rand 12 Item Health Survey. PCS, MCS, and health utilities were summarized by migraine-related disability levels and gender. Covariate-adjusted linear regressions were used to examine the association between migraine disability level and health utility by gender.

RESULTS

A total of 441 participants completed the survey. The sample was predominantly women (60.1%), White race (75.5%), and had a mean age of 37 years. Mean health utility, PCS, and MCS scores were 0.61 (0.22), 45.0 (7.7), and 43.4 (11.0), respectively. All three scores decreased with increased migraine disability level. Gender differences on HRQoL within each migraine disability level were not statistically significant, except in the little to no disability level where women had lower mean MCS scores and health utility relative to men [mean (SD) MCS: women 44.0 (11.3); men 55.1 (8.1), p < 0.001; health utility: women 0.66 (0.18); men 0.81 (0.18), p < 0.001]. Linear regressions showed women with severe migraine-related disability had reduced health utility compared to women with little to no disability [adjusted difference: -0.16 (95%CI -0.24,-0.09)]. Associations among men increased in magnitude with migraine disability level [adjusted differences: mild - 0.16 (95%CI -0.24,-0.09); moderate - 0.18 (95%CI -0.26,-0.10); severe - 0.28 (95%CI -0.37,-0.20)].

CONCLUSIONS

Findings contribute to the literature on the association between migraine disability level and HRQoL by examining trends by gender. Model results emphasize the importance of future treatments reducing severe disability due to migraine among both women and men.

Preventive drug treatments for adults with chronic migraine: a systematic review with economic modelling

Background

Chronic migraine is a disabling condition, affecting 2-4% of adults globally. With the introduction of expensive calcitonin gene-related peptide monoclonal antibodies, it is timely to compare the clinical effectiveness and cost-effectiveness of preventive drugs for chronic migraine.

Objective

To assess the clinical effectiveness and cost-effectiveness of medications used for chronic migraine through systematic reviews and economic modelling.

Eligibility criteria

Randomised controlled trials of drug treatments for efficacy with > 100 participants with chronic migraine per arm; for adverse events > 100 participants with episodic or chronic migraine per arm. Previous economic analyses of preventive drugs for chronic migraine.

Data sources

Eight databases.

Reviews methods

Systematic reviews, network meta-analysis and economic modelling.

Outcomes

Monthly headache days, monthly migraine days, headache-related quality of life, cost-effectiveness.

Results

We found 51 individual articles, reporting 11 randomised controlled trials, testing 6 drugs (topiramate, Botox, eptinezumab, erenumab, fremanezumab, galcanezumab), versus placebo, on 7352 adults with chronic migraine. Calcitonin gene-related peptide monoclonal antibodies, Botox and topiramate reduced headache/migraine days by 2.0-2.5, just under two, or by less than 1.5 days per month, respectively. In the network meta-analysis, eptinezumab 300 mg and fremanezumab monthly ranked in first place in both monthly headache day and monthly migraine day analyses. The calcitonin gene-related peptide monoclonal antibodies were consistently the best choices for headache/migraine days and headache-related quality of life. Topiramate was very unlikely to be the best choice for headache/migraine days and headache-related quality of life when compared to calcitonin gene-related peptide monoclonal antibodies or Botox. We found no trials of the commonly used drugs, such as propranolol or amitriptyline, to include in the analysis. The adverse events review included 40 randomised controlled trials with 25,891 participants; 3 additional drugs, amitriptyline, atogepant and rimegepant, were included. There were very few serious adverse events - none of which were linked to the use of these medications. Adverse events were common. Most people using some calcitonin gene-related peptide monoclonal antibodies reported injection site issues; and people using topiramate or amitriptyline had nervous system or gastrointestinal issues. The cost-effectiveness review identified 16 studies evaluating chronic migraine medications in adults. The newer, injected drugs are more costly than the oral preventatives, but they were cost-effective. Our economic model showed that topiramate was the least costly option and had the fewest quality-adjusted life-year gains, whereas eptinezumab 300 mg was more costly but generated the most quality-adjusted life-year gains. The cost-effectiveness acceptability frontier showed that topiramate was the most cost-effective medication if the decision maker is willing to pay up to £50,000 per quality-adjusted life-year. Our consensus workshop brought together people with chronic migraine and headache experts. Consensus was reached on the top three recommendations for future research on medications to prevent chronic migraine: (1) calcitonin gene-related peptide monoclonal antibodies and Botox versus calcitonin gene-related peptide monoclonal antibodies, (2) candesartan versus placebo and (3) flunarizine versus placebo.

Limitations

Topiramate was the only oral drug for which we were able to include data. We did not find sufficient quality evidence to support the use of other oral drugs.

Conclusions

We did not find evidence that the calcitonin gene-related peptide monoclonal antibodies are more clinically and cost-effective when compared to topiramate or Botox. We identified directions for future research these drugs might take.

Study registration

This study is registered as PROSPERO CRD42021265990, CRD42021265993 and CRD42021265995.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR132803) and is published in full in Health Technology Assessment; Vol. 28, No. 63. See the NIHR Funding and Awards website for further award information.

Epidemiological linkage between migraine and diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

This study aimed to elucidate the nature and extent of the associations between diabetes mellitus (DM) and migraine through a systematic review and meta-analysis.

METHODS

We searched the PubMed, Web of Science, and Scopus databases without a specified start date until June 2, 2024. Cross-sectional and cohort studies analyzing the risk of migraine in individuals with DM and vice versa were included. Studies without at least age and sex adjustments were excluded. Data were extracted to calculate odds ratios (ORs) and hazard ratios (HRs). Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Eight cross-sectional studies (131,361 patients with DM and 1,005,604 patients with migraine) and four cohort studies (103,205 patients with DM patients and 32,197 patients with migraine) were included. Meta-analyses of the cross-sectional studies showed no significant overall association between DM and migraine. Subgroup analyses revealed that type 1 diabetes reduced the odds of having migraine (OR 0.48, 95% confidence interval [CI] 0.30-0.77), while migraine without aura (MO) increased the odds of having DM (OR 1.19, 95% CI 1.02-1.39). The cohort studies indicated that DM decreased the risk of developing migraine (HR 0.83, 95% CI 0.76-0.90), and a history of migraine increased the risk of developing DM (HR 1.09, 95% CI 1.01-1.17).

CONCLUSIONS

DM, particularly type 1 diabetes, is negatively associated with migraine occurrence, whereas migraine, especially MO, is positively associated with DM occurrence. However, most of the results remained at a low or very low level of evidence, indicating the need for further research.

Effect of Ubrogepant on Patient-Reported Outcomes When Administered During the Migraine Prodrome: Results From the Randomized PRODROME Trial

BACKGROUND AND OBJECTIVES

Ubrogepant is a calcitonin gene-related peptide receptor antagonist approved for the acute treatment of migraine. The PRODROME trial previously demonstrated that ubrogepant treatment during prodrome prevents the onset of moderate or severe headache. In this analysis of the PRODROME trial, the benefits of ubrogepant treatment during the prodrome on patient-reported outcomes (PROs) are evaluated.

METHODS

PRODROME was a multicenter, randomized, double-blind, placebo-controlled, crossover trial that enrolled adults who experienced 2-8 migraine attacks per month with moderate-severe headache pain. Eligible participants treated 2 qualifying prodrome events, defined as a migraine attack with prodromal symptoms when the participant was confident a headache would follow within 1-6 hours. Participants were randomized to treatment sequence A (placebo then ubrogepant 100 mg) or sequence B (ubrogepant 100 mg then placebo). This analysis evaluated the ability to function normally over 24 hours (secondary end point) and at specific time points after dose (additional end point). Other PRO end points included activity limitation over 24 hours and satisfaction with study medication at 8 and 24 hours.

RESULTS

Of 518 randomized participants, 477 comprised the modified intent-to-treat population. After treatment of qualifying prodrome events, a significantly greater ability to function normally over 24 hours was observed for participants after treatment with ubrogepant 100 mg compared with placebo (odds ratio [OR] 1.66, 95% CI 1.40-1.96; p < 0.0001). As early as 2 hours after dose, a greater proportion of ubrogepant-treated participants reported "no disability, able to function normally" compared with placebo (OR 1.76, 95% CI 1.32-2.35; nominal p = 0.0001). Ubrogepant administered during the prodrome was also associated with a greater reduction in activity limitations over 24 hours after dose (OR 2.07, 95% CI 1.61-2.67; nominal p < 0.0001). At 8 and 24 hours after dose, rates of being "satisfied" or "extremely satisfied" were greater for ubrogepant than for placebo (8 hours: OR 2.37, 95% CI 1.78-3.15; nominal p < 0.0001; 24 hours: OR 2.32, 95% CI 1.78-3.02; nominal p < 0.0001).

DISCUSSION

Ubrogepant 100 mg administered during the prodrome was associated with significantly greater ability to function normally, greater reduction in activity limitations over 24 hours, and greater satisfaction with study medication, compared with placebo.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov NCT04492020. Submitted: July 27, 2020; first patient enrolled: August 21, 2020. clinicaltrials.gov/ct2/show/NCT04492020.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that taking ubrogepant 100 mg during a migraine prodrome allows more patients to function normally over the next 24 hours.

Treatment Patterns and Persistence Among Patients Newly Diagnosed With Migraine in South Korea: A Retrospective Analysis of Health Claims Data

BACKGROUND AND PURPOSE

Migraine is one of the most common chronic neurological diseases worldwide. Although diverse treatment regimens have been recommended, there is insufficient evidence for which treatment patterns to apply in routine clinical settings.

METHODS

We used nationwide claims data from South Korea for 2015-2021 to identify incident migraine patients with at least one prescription for migraine. Patients were categorized according to their initial treatment classes and followed up from the date of treatment initiation. Treatment regimens included prophylactic treatments (antidepressants, anticonvulsants, beta blockers, calcium-channel blockers, and renin-angiotensin-aldosterone system [RAAS] inhibitors) and acute treatments (acetaminophen, antiemetics, aspirin, ergotamine, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, and triptans). The treatment patterns of migraine were evaluated until the end of the study period, including the secular trends, prevalence, persistence, and changes in migraine treatment.

RESULTS

Among the 761,350 included patients who received migraine treatment, the most frequently prescribed acute treatment was an NSAID (69.9%), followed by acetaminophen (50.0%). The most-prescribed prophylactic treatment was flunarizine (36.9%), followed by propranolol (24.4%). Among the patients, 54.8% received acute treatment, 13.5% received prophylactic treatment, and 31.6% received both treatment types. However, 65.7% of the patients discontinued their treatment within 3 months. The 3-month persistence rate was highest for triptans (25.2%) among the acute treatments and for RAAS inhibitors (62.0%) among the prophylactic treatments.

CONCLUSIONS

While the prevalence rates of medication use were found to align with current migraine guidelines, frequent switching and rapid discontinuation of drugs were observed in routine clinical settings.

Artificial Intelligence and Virtual Reality in Headache Disorder Diagnosis, Classification, and Management

PURPOSE OF REVIEW

This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders.

RECENT FINDINGS

Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

Effect of Smoking on the Development of Migraine in Women: Nationwide Cohort Study in South Korea

Background

Smoking is known to be a significant risk factor for various diseases. Migraine, a condition requiring careful lifestyle management, currently lacks specific guidelines advocating for smoking cessation as a preventive measure. Although cross-sectional studies have suggested a potential link between smoking and an increased risk of migraine, the findings have been inconsistent and conflicting. To date, there has been no longitudinal study which investigated the effect of smoking on the risk of migraine in a prospective setting.

Objective

This longitudinal study aimed to investigate the impact of smoking on the incidence of migraine in women and examine the modifying effect of menopausal status.

Methods

Using nationally representative National Health Insurance Service (NHIS) data, women aged ≥40 years who participated in national breast cancer screening in 2009 were followed-up until the end of 2019. Baseline data on smoking status (non-, ex-, and current smoker) as well as the duration and amount of cigarette smoking were collected. A Cox proportional hazards regression model was used to examine the independent effect of smoking on the risk of incident migraine after adjusting for demographics, comorbidities, and female reproductive factors. The results were stratified by menopausal status, and an interaction analysis (smoking × menopause) was performed.

Results

In total, 1,827,129 women were included in the analysis. Women with a history of smoking exhibited a higher risk of developing migraine, compared with nonsmokers. Specifically, a higher risk of migraine was observed in women with past (adjusted hazard ratio [HR] 1.044, 95% CI 1.000-1.089) and current cigarette use (adjusted HR 1.050, 95% CI, 1.023-1.079) than in nonsmokers. The effect was greater in premenopausal women (adjusted HR 1.140, 95% CI, 1.108-1.172) than in postmenopausal women (adjusted HR 1.045, 95% CI 1.018-1.073; P<.001). The risk increased with an increased amount of smoking, with a greater association in premenopausal women (P<.001).

Conclusions

Smoking increases the risk of migraine in women, with a dose-dependent relationship. Menopause modifies this effect. Our findings suggest that smoking is an important modifiable risk factor of migraine, with a higher impact in premenopausal women. The interaction between smoking and estrogen may increase the vulnerability of the migraine brain.

Inflammo-immune perspective on the association of eight migraine risk factors with migraine: a multi-omics Mendelian randomization study

Background

Migraine risk factors are associated with migraine susceptibility, yet their mechanisms are unclear. Evidence suggests a role for inflammatory proteins and immune cells in migraine pathogenesis. This study aimed to examine the inflammo-immune association between eight migraine risk factors and the disorder.

Methods

This study utilized inverse variance weighted (IVW) method and colocalization analysis to explore potential causal relationships between eight migraine risk factors, migraine, 731 immune cells, and 91 circulating inflammatory proteins. Mediation Mendelian randomization (MR) was further used to confirm the mediating role of circulating inflammatory proteins and immune cells between the eight migraine risk factors and migraine.

Results

Migraine risk factors are linked to 276 immune cells and inflammatory proteins, with cigarettes smoked per day strongly co-localized with CD33-HLA DR+ cells. Despite no co-localization, 23 immune cells/inflammatory proteins relate to migraine. Depression, all anxiety disorders, and sleep apnea are correlated with migraine, and all anxiety disorders are supported by strong co-localization evidence. However, the mediating effect of inflammatory proteins and immune cells between eight migraine risk factors and migraine has not been confirmed.

Conclusion

We elucidate the potential causal relationships between eight migraine risk factors, migraine, immune cells, and inflammatory proteins, enhancing our understanding of the molecular etiology of migraine pathogenesis from an inflammatory-immune perspective.

Association between patent foramen ovale and migraine: evidence from a resting-state fMRI study

A relationship between migraine without aura (MO) and patent foramen ovale (PFO) has been observed, but the neural basis underlying this relationship remains elusive. Utilizing independent component analysis via functional magnetic resonance imaging, we examined functional connectivity (FC) within and across networks in 146 patients with MO (75 patients with and 71 patients without PFO) and 70 healthy controls (35 patients each with and without PFO) to elucidate the individual effects of MO and PFO, as well as their interaction, on brain functional networks. The main effect of PFO manifested exclusively in the FC among the visual, auditory, default mode, dorsal attention and salience networks. Furthermore, the interaction effect between MO and PFO was discerned in brain clusters of the left frontoparietal network and lingual gyrus network, as well as the internetwork FC between the left frontoparietal network and the default mode network (DMN), the occipital pole and medial visual networks, and the dorsal attention and salience networks. Our findings suggest that the presence of a PFO shunt in patients with MO is accompanied by various FC changes within and across networks. These changes elucidate the intricate mechanisms linked to PFO-associated migraines and provide a basis for identifying novel noninvasive biomarkers.

Health care resource utilization and direct costs incurred over 24 months after initiating galcanezumab or standard-of-care preventive migraine treatments in the United States

BACKGROUND

Health care resource utilization (HCRU) and direct costs incurred over 12 months following initiation of galcanezumab (GMB) or standard-of-care (SOC) preventive migraine treatments have been evaluated. However, a gap in knowledge exists in understanding longer-term HCRU and direct costs.

OBJECTIVE

To compare all-cause and migraine-related HCRU and direct costs in patients with migraine initiating GMB or SOC preventive migraine treatments over a 24-month follow-up.

METHODS

This retrospective study used Optum deidentified Market Clarity Data. The study included adults diagnosed with migraine, with at least 1 claim for GMB or SOC preventive migraine therapy (September 2018 to March 2020), with continuous enrollment for 12 months before and 24 months after (follow-up) the index date (date of first GMB or SOC claim). Propensity score (PS) matching (1:1) was used to balance cohorts. All-cause and migraine-related HCRU and direct costs for GMB vs SOC cohorts were reported as mean (SD) per patient per year (PPPY) over a 24-month follow-up and compared using a Z-test. Costs were inflated to 2022 US$.

RESULTS

After PS matching, 2,307 patient pairs (mean age: 44.4 years; female sex: 87.3%) were identified. Compared with the SOC cohort, the GMB cohort had lower mean (SD) PPPY all-cause office visits (17.9 [17.7] vs 19.1 [18.7]; P = 0.023) and migraine-related office visits (2.6 [3.3] vs 3.0 [4.7]; P = 0.002) at follow-up. No significant differences were observed between cohorts in other all-cause and migraine-related events assessed including outpatient visits, emergency department (ED) visits, inpatient stays, and other medical visits. The mean (SD) costs PPPY were lower in the GMB cohort compared with the SOC cohort for all-cause office visits ($4,321 [7,518] vs $5,033 [7,211]; P < 0.001) at follow-up. However, the GMB cohort had higher mean (SD) PPPY all-cause total costs ($24,704 [30,705] vs $21,902 [28,213]; P = 0.001) and pharmacy costs ($9,507 [12,659] vs $5,623 [12,605]; P < 0.001) compared with the SOC cohort. Mean (SD) costs PPPY were lower in the GMB cohort for migraine-related office visits ($806 [1,690] vs $1,353 [2,805]; P < 0.001) compared with the SOC cohort. However, the GMB cohort had higher mean (SD) PPPY migraine-related total costs ($8,248 [11,486] vs $5,047 [9,749]; P < 0.001) and migraine-related pharmacy costs ($5,394 [3,986] vs $1,761 [4,133]; P < 0.001) compared with the SOC cohort. There were no significant differences between cohorts in all-cause and migraine-related costs for outpatient visits, ED visits, inpatient stays, and other medical visits.

CONCLUSIONS

Although total costs were greater for GMB vs SOC following initiation, changes in a few categories of all-cause and migraine-related HCRU and direct costs were lower for GMB over a 24-month follow-up. Additional analysis evaluating indirect health care costs may offer insights into further cost savings incurred with preventive migraine treatment.

Underrecognition of migraine-related stigmatizing attitudes and social burden: Results of the OVERCOME Japan study

INTRODUCTION

Migraine-related stigma (MiRS) and social burden is increasingly recognized. We assessed perspectives and attitudes toward migraine in people with and without migraine in Japan.

METHODS

OVERCOME (Japan) was a cross-sectional, population-based web survey of people with and without migraine (July-September 2020). People with migraine were individuals who met the modified International Classification of Headache Disorders criteria or had self-reported physician-diagnosed migraine. People without migraine were selected per quota sampling to represent the Japanese adult population. People with migraine reported their experiences on stigma and social burden and answered how frequently they experienced stigma using the MiRS questionnaire. Associations between MiRS and disability and MiRS and interictal burden were examined using the migraine disability assessment and Migraine Interictal Burden Scale-4. People without migraine reported their experiences and attitudes toward people with migraine by answering an 11-item attitudinal migraine questionnaire.

RESULTS

A total of 17,071 and 2008 people with and without migraine, respectively, completed the survey. Overall, 11,228 (65.8%) respondents with migraine reported that they have never experienced stigma or burden; however, of the 12,383 employed respondents, 5841 (47.2%) reported that their current employers are not "extremely" or "very" understanding about their conditions. Moreover, ∼30%-40% of respondents "sometimes," "often," or "very often" hid their migraine from others. The proportion of respondents who experienced stigma often or very often, as assessed by MiRS, was 16.5%; this increased with the increasing number of monthly migraine headache days. The proportion of respondents with moderate-to-severe disability and interictal burden increased with increasing stigma. Among respondents without migraine, the proportion holding a stigmatizing attitude toward those with migraine was low (<15%); ∼80% had never experienced work- or family-related stigma or burden.

CONCLUSION

MiRS and burden exist but may be hidden and underrecognized in Japan. Disease awareness and education may be important to prevent and reduce stigma and burden.

Revolutionizing migraine management: advances and challenges in CGRP-targeted therapies and their clinical implications

Migraine, a prevalent neurological disorder, affects approximately 14.1% of the global population and disproportionately impacts females. This debilitating condition significantly compromises quality of life, productivity, and incurs high healthcare costs, presenting a challenge not only to individuals but to societal structures as a whole. Despite advances in our understanding of migraine pathophysiology, treatment options remain limited, necessitating ongoing research into effective therapies. This review delves into the complexity of migraine management, examining the roles of genetic predisposition, environmental influences, personalized treatment approaches, comorbidities, efficacy and safety of existing acute and preventive treatments. It further explores the continuum between migraine and tension-type headaches and discusses the intricacies of treating various migraine subtypes, including those with and without aura. We emphasize the recent paradigm shift toward trigeminovascular activation and the release of vasoactive substances, such as calcitonin gene-related peptide (CGRP), which offer novel therapeutic targets. We assess groundbreaking clinical trials, pharmacokinetic and pharmacodynamic perspectives, safety, tolerability, and the real-world application of CGRP monoclonal antibodies and gepants. In the face of persisting treatment barriers such as misdiagnosis, medication overuse headaches, and limited access to specialist care, we discuss innovative CGRP-targeted strategies, the high cost and scarcity of long-term efficacy data, and suggest comprehensive solutions tailored to Turkiye and developing countries. The review offers strategic recommendations including the formulation of primary care guidelines, establishment of specialized outpatient clinics, updating physicians on novel treatments, enhancing global accessibility to advanced therapies, and fostering patient education. Emphasizing the importance of lifestyle modifications and holistic approaches, the review underscores the potential of mass media and patient groups in disseminating critical health information and shaping the future of migraine management.

Global, regional, and national burden and trends of migraine among women of childbearing age from 1990 to 2021: insights from the Global Burden of Disease Study 2021

BACKGROUND

Migraine, a neurological disorder with a significant female predilection, is the leading cause of disability-adjusted life years (DALYs) in women of childbearing age (WCBA). There is currently a lack of comprehensive literature analysis on the overall global burden and changing trends of migraines in WCBA.

METHODS

This study extracted three main indicators, including prevalence, incidence, and DALYs, related to migraine in WCBA from the Global Burden of Disease(GBD) database from 1990 to 2021. Our study presented point estimates with 95% uncertainty intervals (UIs). It evaluated the changing trends in the burden of migraine in WCBA using the estimated annual percentage change (EAPC) and percentage change.

RESULTS

In 2021, the global prevalence, incidence, and DALYs cases of migraine among WCBA were 493.94 million, 33.33 million, and 18.25 million, respectively, with percentage changes of 48%, 43%, and 47% compared to 1990. Over the past 32 years, global prevalence rates and DALYs rates globally have increased, with an EAPC of 0.03 (95% UI: 0.02 to 0.05) and 0.04 (95% UI: 0.03 to 0.05), while incidence rates have decreased with an EAPC of -0.07 (95% UI: -0.08 to -0.05). Among the 5 Socio-Demographic Index (SDI) regions, in 2021, the middle SDI region recorded the highest cases of prevalence, incidence, and DALYs of migraine among WCBA, estimated at 157.1 million, 10.56 million, and 5.81 million, respectively, approximately one-third of the global total. In terms of age, in 2021, the global incidence cases for the age group 15-19 years were 5942.5 thousand, with an incidence rate per 100,000 population of 1957.02, the highest among all age groups. The total number of migraine cases and incidence rate among WCBA show an increasing trend with age, particularly in the 45-49 age group.

CONCLUSIONS

Overall, the burden of migraine among WCBA has significantly increased globally over the past 32 years, particularly within the middle SDI and the 45-49 age group. Research findings emphasize the importance of customized interventions aimed at addressing the issue of migraines in WCBA, thus contributing to the attainment of Sustainable Development Goal 3 set by the World Health Organization.

Genetic evidence for the causal relationships between migraine, dementia, and longitudinal brain atrophy

BACKGROUND

Migraine is a neurological disease with a significant genetic component and is characterized by recurrent and prolonged episodes of headache. Previous epidemiological studies have reported a higher risk of dementia in migraine patients. Neuroimaging studies have also shown structural brain atrophy in regions that are common to migraine and dementia. However, these studies are observational and cannot establish causality. The present study aims to explore the genetic causal relationship between migraine and dementia, as well as the mediation roles of brain structural changes in this association using Mendelian randomization (MR).

METHODS

We collected the genome-wide association study (GWAS) summary statistics of migraine and its two subtypes, as well as four common types of dementia, including Alzheimer's disease (AD), vascular dementia, frontotemporal dementia, and Lewy body dementia. In addition, we collected the GWAS summary statistics of seven longitudinal brain measures that characterize brain structural alterations with age. Using these GWAS, we performed Two-sample MR analyses to investigate the causal effects of migraine and its two subtypes on dementia and brain structural changes. To explore the possible mediation of brain structural changes between migraine and dementia, we conducted a two-step MR mediation analysis.

RESULTS

The MR analysis demonstrated a significant association between genetically predicted migraine and an increased risk of AD (OR = 1.097, 95% CI = [1.040, 1.158], p = 7.03 × 10- 4). Moreover, migraine significantly accelerated annual atrophy of the total cortical surface area (-65.588 cm2 per year, 95% CI = [-103.112, -28.064], p = 6.13 × 10- 4) and thalamic volume (-9.507 cm3 per year, 95% CI = [-15.512, -3.502], p = 1.91 × 10- 3). The migraine without aura (MO) subtype increased the risk of AD (OR = 1.091, 95% CI = [1.059, 1.123], p = 6.95 × 10- 9) and accelerated annual atrophy of the total cortical surface area (-31.401 cm2 per year, 95% CI = [-43.990, -18.811], p = 1.02 × 10- 6). The two-step MR mediation analysis revealed that thalamic atrophy partly mediated the causal effect of migraine on AD, accounting for 28.2% of the total effect.

DISCUSSION

This comprehensive MR study provided genetic evidence for the causal effect of migraine on AD and identified longitudinal thalamic atrophy as a potential mediator in this association. These findings may inform brain intervention targets to prevent AD risk in migraine patients.

Migraine incidence and coffee consumption among child-bearing age women: the Korea Nurses' Health Study

This longitudinal study aimed to identify factors that influence migraines in Korean women nurses using data from the Korea Nurses' Health Study. Among those who participated in Survey 1 (2013-2014) and the follow-up survey (2015-2019), we selected 2605 participants for Cox proportional hazard regression analysis, 521 participants who were newly diagnosed with migraine and 2084 controls using a 1:4 incidence density sampling approach. Consuming coffee (≥ 3 cups: RR = 1.666; 95% CI = 1.175-2.362, < 3 cups: RR = 1.439; 95% CI = 1.053-1.966), being obese (BMI ≥ 25: RR = 1.341, 95% CI = 1.003-1.793), and engaging in vigorous physical activity (RR = 1.010; 95% CI = 1.000-1.019) increased the risk of developing a migraine. Nurses with an annual salary greater than $3500 were less likely to develop migraines (RR = 0.786, 95% CI = 0.631-0.979). The results imply that lifestyle factors, such as the amount of coffee consumption, BMI level, and degree of physical activity could be considered when formulating treatment plans for women who have newly developed migraines.

Association between migraine and pre-eclampsia among pregnant women: a single hospital-based case-control study in India

BACKGROUND

Pre-eclampsia and migraine share some similar aspects of pathophysiology such as vascular function, platelet activation, and enhanced clotting. A few observational studies from different demographics showed that pregnant women with a history of migraine were at higher risk of developing pre-eclampsia. However, there is no such evidence available from the Indian context. Hence, a hospital-based case-control study was conducted among Indian women to determine the association between migraine and pre-eclampsia.

METHOD

It was a single-centre case-control study in a tertiary care hospital in India. Cases were pregnant women with clinically diagnosed pre-eclampsia, and controls were normotensive pregnant women. Migraine was diagnosed with a questionnaire adapted from the "International Classification of Headache Disorders (ICHD), 3rd Edition" by the International Headache Society, (IHS). We performed logistic regression to explore the association between migraine and pre-eclampsia.

RESULT

One hundred sixty-four women (82 women per group) were enrolled. The mean age among the cases (24.5 years, standard deviation of 2.4 years) was slightly higher than the mean age of the controls (23.5 years, standard deviation of 2.5 years) with a p-value of 0.006. We found that women with a history of migraine were more likely to develop pre-eclampsia (Adjusted Odds Ratio 6.17; p-value < 0.001, 95% Confidence Interval of 2.85 to 13.62).

CONCLUSION

The current findings suggest a significant association between migraine and pre-eclampsia aligning with previous study findings; nevertheless, larger follow-up studies including women from different states in India are needed.